High Reliability Organizing for Process Safety: Principles ... · High Reliability Organizing for...

© Cranfield University 2008 © Cranfield University 2014

High Reliability Organizing for Process Safety: Principles, Practices and Leadership CCPS Process Safety Summit Mumbai, India, 15 Dec 2014 Charles Cowley Doctoral Researcher, Cranfield University, UK, School of Management (CCPS Staff Consultant, ex Shell)


Background

Texas City 1947 Flixborough 1974 Seveso 1976 Tenerife 1977 Chicago DC10 1979 Three Mile Island 1979 Mexico City 1984 Bhopal 1984 Chernobyl 1986 Zeebrugge 1987 Piper Alpha 1988 Exxon Valdez 1989

Rapid industrialization since the mid-20th century - Many serious incidents:


Bhopal remembered…

© Cranfield University 2008 © Cranfield University 2014 Time

Num

bers

of

Inci

dent

s

Technology

Management Systems • Engineering Standards

• Equipment design

• Mgt of Change

• Maint & Inspection

• Procedures/rules

• Certification

• Competence

• Risk Assessment

Historical approaches to improvement


Background to HRO

1980s - cross-disciplinary (psychologists & sociologists) research in the US,

on several organizations that, despite operating with high hazards,

appeared to have very few accidents:

….Beginnings of 'HRO’ theory (Karlene Roberts, Todd LaPorte, Gene Rochlin)

Aircraft carriers Air Traffic Control Commercial Nuclear Power


HRO Theory – some key ideas from 80s research

HROs have active organisational and interpersonal processes that reduce and contain human errors and system failures:

“everyone knows the big picture and constantly communicates that understanding…”

leaders encourage strong responses to weak signals by rewarding reporting of errors and defects and avoiding individual blame;

HROs are adept at coping with paradoxes: eg:

standardisation AND flexibility: standardised procedures AND deliberate flexibility to encourage creativity in problem-solving: …some organisational ‘slack’ and multi-skilling are needed

trust AND challenge / respectful cross-checking (good teamwork)

Prof Karlene Roberts, University of California - Berkeley 1990


More HRO Theory (Karlene Roberts)

• Focus on past success

• Underdeveloped cognitive infrastructure

• Focus on efficiency

• Inefficient learning (episodic)

• Lack of diversity (focused conformity)

• Information & communications filtering

• Reject early warning signs of quality degradations

Non-HROs


EXAMPLE of HROs: Commercial Aviation

Source: Boeing Commercial Airplanes 2010 STATISTICAL SUMMARY, JUNE 2011


Accidents continue in 21st century

Texas City 1947 Flixborough 1974 Seveso 1976 Tenerife 1977 Chicago DC10 1979 Three Mile Island 1979 Mexico City 1984 Bhopal 1984 Chernobyl 1986 Zeebrugge 1987 Piper Alpha 1988 Exxon Valdez 1989

Despite improved engineering and management,

serious incidents continue… Columbia Space Shuttle, USA 2003 Texas City Refinery, USA 2005 Buncefield, UK 2005 Guangxi, China 2008 Jaipur, India 2009 Yichun, China 2010 Gulf of Mexico Macondo 2010 Fukushima, Japan 2011 Xintai, China 2011 Lac-Mégantic, Canada 2013 Visakhapatnam refinery, India 2013 Soma Manisa, Turkey coal mine 2014 Kaohsiung, China 2014 Changsa, China 2014


Background to HRO

Today - renewed interest in HRO in the process industry after the continued series of major incidents in the 2000s

© Cranfield University 2008 © Cranfield University 2014 Time

Num

bers

of

Inci

dent

s

Technology

Management Systems • Engineering Standards

• Equipment design

• Mgt of Change

• Maint & Inspection

• Procedures/rules

• Certification

• Competence

• Risk Assessment • Mindfulness

• Teamwork

• Situation Awareness

• Leadership

Culture…HRO

Management Systems


Many Theories of Major Accident Risk Management

Normal Accident Theory

Safety Culture

Resilience Engineering

System Safety

HRO ‘5 Characteristics model’

Mindful Leadership

Major Accident Risk

Management

Crew Resource Management

Situation Awareness

Other HRO theories


HRO Theory – some key ideas… 2001

‘Mindful sense-making’…

Preoccupation with failure

Reluctance to simplify explanations

Sensitivity to operations

Commitment to resilience

Deference to expertise

Weick & Sutcliffe 2001


HRO - 5 Characteristics of Mindfulness (W&S)

Preoccupation with failure ‘Chronic unease’ …..Reporting culture …..Strong response to weak signals

Reluctance to simplify explanations Avoid loss of critical information AND capacity for analysis, reflection, learning

Sensitivity to operations High situational awareness: control room and boardroom

Commitment to resilience ‘a single error must not result in an accident’ (T Kletz) …learning from errors

Deference to expertise Mindful competent decision-making with incomplete info or in unforeseen conditions


Situation Awareness

Level 1: Perception of information about what is happening

Level 2 - Interpretation of what the information means for me and my task

Level 3 - Projection of what is likely to happen in the immediate future

Dr. Mica Endsley http://www.satechnologies.com/

Level 3: Projection

Level 2: Interpretation

Level 1: Perception

Situation Awareness Events in the world

Do I need to take action?

Neatly summarised as: What? So what? Now what?

“In HROs everyone knows the big picture and constantly communicates that understanding…” Karlene Roberts

http://www.satechnologies.com/


HRO - 5 Characteristics of Mindfulness (W&S)

Preoccupation with failure ‘Chronic unease’ …..Reporting culture …..Strong response to weak signals

Reluctance to simplify explanations Avoid loss of critical information AND capacity for analysis, reflection, learning

Sensitivity to operations High situational awareness: control room and boardroom

Commitment to resilience ‘a single error must not result in an accident’ (T Kletz) …learning from errors

Deference to expertise Mindful competent decision-making with incomplete info or in unforeseen conditions

Strong response to weak signals


Weak signals – Weick and Sutcliffe

The key difference between HROs and other organisations...often occurs in the earliest stages, when the unexpected may give off only weak signals of trouble

The overwhelming tendency is to respond to weak signals with a weak response. Mindfulness preserves the capability to see the significant meaning of weak signals and to give strong responses to weak signals

HROs don’t necessarily see discrepancies any more quickly, but when they do spot discrepancies, they understand their meaning more fully and can deal with them more confidently

Weick, K.E. and Sutcliffe, K.M. (2007) Managing the Unexpected. Resilient Performance in an Age of Uncertainty. 2nd Edition John Wiley


Weak Signals: event detection

False alarm Failure of detection

Correct alarm

Noise Signal

Non-event Detection threshold

Signal to noise ratio

Signal strength

Number of events


Fast and Slow Thinking… Daniel Kahneman

‘Slow’ thinking Deliberate Effortful

‘Fast’ thinking Intuitive Effortless

Jumps to conclusions

Suppresses ambiguity

Automatic (Always on)

Reasoning, Checking

Sees ambiguity; experiences doubt

Controlled (Off unless turned on)

Daniel Kahneman, ‘Thinking, Fast and Slow’ 2011

‘Normal operating’ …systems; procedures; Operational Discipline

‘Mindful sense-making’ …


Two ‘Operating Models’ – competing or complementing?

‘System Safety’ - system, procedures and

rule-following • Analytical Risk Management • System design • Overcome NAT by design • Decision-making processes • TQM - Safety Mgt Systems • Operational discipline

‘HRO’ - mindful sense-making

• Preoccupation with failure • Reluctance to simplify • Sensitivity to operations • Commitment to resilience • Deference to expertise AND • Organisational ‘slack’ • Flexibility of structure • Overcome NAT by processes

Organising for High Reliability

and Safety

Common features

• Situation awareness • Competence • ‘Just’ culture • Organisational learning


The wider HRO landscape …reviewed in 2011

UK Health & Safety Executive 2011


‘Leadership for Process Safety’

OECD Guidance Guidance for Senior Leaders in High Hazard Industries

OGP 452 –Shaping Safety Culture through Safety Leadership

CCPS Inspiring Process Safety Leadership

- The Executive Role

IChemE / EPSC Process Safety Leadership

for Senior Executives (PSL)

UK HSE Leadership for the major hazard industries

Process Safety Leadership Group ‘Principles’

….other


‘Mindful Leadership’ – some key components?

Chronic Unease

‘Just’ culture

Engaging – especially with front line operations

Sense-making and Integrating

Committing to provide adequate resources

Challenging and supporting people…


Is this how Leadership influences HRO development? (This is CURRENT RESEARCH…)

Leadership roles eg:

• Chronic unease

• ‘Just’ culture

• Engaging

• Sense-making & Integrating

• Allocating resources

• Challenging & Supporting

HRO Components: Processes, Structures, Systems, Practices …eg:

• Decision processes

• Centralised organisation

• Use of Leading Indicators

• Operational discipline

• Error Management /CRM


Context eg: • Organization’s type of activity: Technological Sociological • Hazard Consequences • Regulatory Political Litigational • Other…

HRO ‘Principles’ • Preoccupation with failure • Reluctance to simplify • Sensitivity to operations • Commitment to resilience • Deference to expertise and…

• Redundancy

• Flexibility of structure

• Competence

• Organisational learning

• System Safety


Macondo, Gulf of Mexico, 10 Apr 2010

EXAMPLE: Gulf of Mexico oil well blowout 2010

26


EXAMPLE: Gulf of Mexico oil well blowout 2010


• Chronic unease


• Engaging


• Adequate resourcing











• Redundancy


• Competence


• System Safety


EXAMPLE: QF32 – A380 Engine Loss 4 Nov 2010 …BUT…disaster averted

http://blogs.crikey.com.au/planetalking/2013/06/27/qf32-how-highest-standards-in-piloting-again-saved-qantas/engine-damage/


EXAMPLE: QF32 – A380 Engine Loss 4 Nov 2010 …BUT…disaster averted


• Chronic unease


• Engaging


• Adequate resourcing











• Redundancy


• Competence


• System Safety


Focus of current research

To identify leadership roles and practices

…that are effective in influencing the development of Highly Reliable Organisations

Contact [email protected]


KEY TAKE-AWAYS As well as Systems, Procedures and ‘Operating Discipline’ we need

‘Mindful Sense-making’ to achieve Situational Awareness

Principles of Mindfulness include:

Preoccupation with failure Reluctance to simplify explanations Sensitivity to operations Commitment to resilience Deference to expertise

‘Mindful Leadership’ practices that contribute may include:

Chronic unease ‘Just’ culture Engaging – especially with front line operations Integrating and Sense-making Adequate resourcing Challenging and Supporting


Thank you…!

Questions ?


BACK-UP

EXTRA SLIDES for further reading or questions…


It is very easy to LOSE (or never gain) high Situation Awareness - • Poor design of operator / system interface • Distraction • Fatigue • Stress • Poor communication within team • Low motivation

• Poor information about the plant, the operating environment... • Lack of knowledge about what is going on down in the shop floor... • Lack of information about process disruptions, near-incidents .... • Poor auditing...

Situation Awareness


High Situation Awareness takes effort • Ergonomic design of operator / system interface • Avoid distractions (alarm management; sterile area... quiet room) • Fatigue management (shift rostering... / breaks... • Stress monitoring / support / coping strategies... • Communication within team (Crew Resource Management... Radio discipline) • Team / shift motivation (supervisor training...)

• Routine recurrent training; use of simulators... • Pre Job Briefings... Frequent team / shift meetings • Rapid sharing of information from plant... Frequent management site visits • Learning From Incidents: process disruptions, near-incidents .... • High value auditing...

Situation Awareness


Operational Discipline

Basic Skills

Proficiency (Currency... Skills maintenance)

Equipment

Self

Team

Situation Awareness

Judgement

Task Environment

Tony Kern’s Airmanship model, applied to process plant

Risk


Increasing Trust & Accountability

Culture Ladder

Increasingly informed

PATHOLOGICAL who cares

as long as we’re not caught

REACTIVE Safety is important, we do a lot every time we have an accident

CALCULATIVE we have systems in place to

manage all hazards

PROACTIVE we work on problems

we know about

GENERATIVE High Reliability Organisations


Energy Institute Hearts and Minds - Home Available from

http://www.eimicrosites.org/heartsandminds/





Further reading

CCPS Risk Based Process Safety Management - 2007

CCPS Conduct of Operations and Operational Discipline - 2011

UK H&S Exec RR899 – HRO Literature Survey - Nov 2011

Leadership and HROs - why banks fail Young, B. 2012

* OGP 452 Safety culture and leadership - Oct 2013

* OGP 460 Cognitive issues in process safety - Jul 2012

* OGP 510 Operating Management Systems - Jun 2014

* OGP 511 OMS in practice - Jun 2014

Energy Institute ‘High level framework for Process Safety’ Dec 2010

http://high-reliability.org/pages/High-Reliability-Organizations










High Reliability Organizing for Process Safety: Principles ... · High Reliability Organizing for...

Documents

Transcript of High Reliability Organizing for Process Safety: Principles ... · High Reliability Organizing for...